Fact Sheet: Children in Residential Treatment Centers

I. Tens of thousands of children with mental health needs are being placed in expensive, inappropriate and often dangerous institutions.

The number of children placed in residential treatment centers (or RTCs)[1] is growing exponentially.[2] These modern-day orphanages now house more than 50,000 children nationwide.[3] Children are packed off to RTCs, often sent by officials they have never met, who have probably never spoken to their parents, teachers or social workers.[4] Once placed, these kids may have no meaningful contact with their families or friends for up to two years.[5] And, despite many documented cases of neglect and physical and sexual abuse, monitoring is inadequate to ensure that children are safe, healthy and receiving proper services in RTCs.[6] By funneling children with mental illnesses into the RTC system, states fail—at enormous cost—to provide more effective community-based mental health services.[7]

A. RTC placements are often inappropriate.

RTCs are among the most restrictive mental health services and, as such, should be reserved for children whose dangerous behavior cannot be controlled except in a secure setting.[8] Too often, however, child-serving bureaucracies hastily place children in RTCs because they have not made more appropriate community-based services available.[9] Parents who are desperate to meet their kids’ needs often turn to RTCs because they lack viable alternatives.[10]

To make placement decisions, families in crisis and overburdened social workers rely on the institutions’ glossy flyers and professional websites with testimonials of saved children.[11] But all RTCs are not alike.[12] Local, state and national exposés and litigation “regarding the quality of care in residential treatment centers have shown that some programs promise high-quality treatment but deliver low-quality custodial care.”[13] As a result, parents and state officials play a dangerous game of Russian roulette as they decide where to place children, because little public information is available about the RTCs, which are under-regulated and under-supervised.

To make it worse, far too many children are placed at great distance from their homes. For example, most District of Columbia children in RTCs are placed outside the District—many as far away as Utah and Minnesota.[14] Many families, especially those with limited means, find it impossible to have any meaningful visitation with their children.

B. Evidence is limited on the effectiveness of RTCs.

Children frequently arrive at RTCs traumatized by the process that delivered them there. They are often forcibly removed from their homes in the middle of the night by “escort companies.”[15] Other times, children are placed in RTCs not by their parents or doctors, but by overburdened child-serving state agencies, who know little about the children’s individual needs.[16]

Even more appalling, many children’s conditions do not improve at all while at the RTC.[17] In fact, there is little evidence that placing children in RTCs has any positive impact at all on their mental health state[18] and any gains made during a stay in an RTC quickly disappear upon discharge, creating a cycle where children return again and again to RTCs.[19]

There are many reasons why RTCs fail to deliver the results they promise, but most center on the type of services provided, the environment they are provided in and the lack of family involvement.

First, the reality of what occurs within an RTC is often quite different from the highly individualized, highly structured programs that are advertised. The RTCs often provide less intense services and the staff are often under-trained.[20] Children spend much of their day with staff who are not much more qualified than the average parent and they spend less time face-to-face with psychiatrists than they would if they were being served in appropriate community settings.[21]

The environment is also problematic because children in RTCs enter a situation where their only peers are other troubled children—a major risk factor for later behavioral problems.[22] Research has demonstrated that some children learn antisocial or bizarre behavior from intensive exposure to other disturbed children.[23]

Children are usually far from home in RTCs, often out-of-state.[24] Removed from their families and natural support systems, they are unable to draw upon the strengths of their communities and their communities are unable to contribute to their treatment. Few children thrive when they are hundreds or thousands of miles from their parents, friends, grandparents and teachers. Few can flourish without the guidance of consistent parenting. Yet, we expect that our most vulnerable and troubled youth will miraculously turn around in just such a situation. Instead, this isolation further reduces the efficacy of treatment and increases its cost.[25]

The fact that children and their families are far from one another creates a host of problems. For one, it makes family therapy difficult or impossible. As a result, when children leave the RTC, they return to an environment that has not changed. Also, because the RTC environment is inherently artificial—children are not asked to negotiate the obstacles that occur within their family setting or deal with the difficulties that trigger their behaviors in their neighborhoods or schools—the child does not gain new skills to better negotiate life outside of an institution. As a result, neither the children nor their parents learn better ways to overcome the obstacles that led to the RTC placement. Without family involvement, successes are limited.[26]

Among the rare children who are able to overcome these obstacles, few can sustain the gains they have made. In one study, nearly 50% of children were readmitted to an RTC, and 75% were either renstitutionalized or arrested.[27]

C. Children suffer because there is no watchdog.

The RTC industry is largely unregulated.[28] RTCs need only report major unusual incidents (or MUIs), but the interpretation of what constitutes an MUI and the reporting requirements vary widely.[29] Some RTCs fail to report MUIs at all—with little consequence.[30] Vulnerable kids are placed far from home where parents, social workers, or the state can offer little oversight or protection. Worse, many of the facilities limit children’s ability to have contact with their parents for extended periods, further restricting the parents’ ability to monitor the facilities.[31]

D. Children are abused in RTCs.

Children placed in RTCs have been sexually and physically abused, restrained for hours, over-medicated and subject to militaristic punishments; some have died.[32] The following are just a few documented examples of tragic occurrences at RTCs:

Medication is often used (and overused) to control behavior.[33] Children have been permanently disfigured because of over-medication.[34]

In some programs, the children’s shoes are confiscated to keep them from running away.[35]

There have been reports of behavioral ‘therapies’ being misused. As one author noted, “Such therapies do little more than systematically punish children, all under the guise of treatment . . . .”[36]

Sexual abuse by staff members and other residents is all too frequent.[37] In one case, a 13-year old girl performed sexual favors for staff members in return for snacks and carryout food.[38] At one RTC, four boys were accused of trying to sodomize another with a cucumber.[39] At another, a 19-year-old woman was charged with sodomizing a 14-year-old girl.[40]

Physical abuse is also too frequent an occurrence. For example, a 13-year-old boy was forced against a wall and slammed to the floor by employees of an RTC.[41]

Children are often restrained—sometimes for hours on end. The overuse of restraint has resulted in child deaths.[42]

E. Tragic outcomes at great public expense.

RTCs have grown to a billion-dollar, largely private industry.[43] Residential treatment care is exorbitantly expensive—costing up to $700 per child per day.[44] Annual costs can exceed $120,000.[45] Most of the time, the public foots the bill for these services.[46] In fact, nearly one fourth of the national outlay on child mental health is spent on care in these settings.[47]

II. Other Interventions Work Better for Less

Home- and community-based services are much more therapeutically effective than institutional services, and are also markedly more cost-efficient. As the Surgeon General reported, “the most convincing evidence of effectiveness is for home-based services and therapeutic foster care” and not for RTCs.[48] A comprehensive system of care would dramatically reduce the number of children in RTCs.[49]

Community-based alternatives produce better short- and long-term results and are less disruptive to children and families. These alternatives provide intensive mental health treatment, mobilize community resources and help children and their families develop effective coping mechanisms. Some models endeavor to “wrap services around” the child, while others emphasize multi-systemic therapy and crisis intervention. Randomized clinical trials found greater declines in delinquency and behavioral problems, greater increases in functioning, greater stability in housing placements and greater likelihood of permanent placement.[50] In Milwaukee, a wraparound project that has served over 700 youth involved in juvenile justice has shown similar promise; use of residential treatment has declined 60%, use of psychiatric hospitalization has declined 80%, and average overall care costs for target youth have dropped by one third.[51]

[2] In 1982, when Jane Knitzer wrote the seminal book, Unclaimed Children, the growth in the RTC industry was only beginning. Ms. Knitzer wrote that: “In contrast to the minimal efforts to create nonresidential services, 18 of the 44 states responding to our survey were working to increase residential care.” Knitzer, J., Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Care,Children’s Defense Fund, 1982, at 45. By 1986, the number of children in RTCs had grown to 25,334, an increase of more than 30% over a three-year period. Rivera, V.R. & Kutash, K. (1994), Components of a System of Care. What Does the Research Say?, Residential Services: Psychiatric Hospitals and Residential Treatment Centers, at 8, Tampa , FL: University of South Florida, Florida Mental Health Institute: The Research and Training Center for Children’s Mental Health. This growth in continuing. See infra, at note 3.

[3] Latest Findings in Children’s Mental Health, Nearly 66,000 Youth Live in U.S, Mental Health Programs, Vo1. 2, No. 1 (Summer 2003). In 1997, the year in which the most recent data was available, more than 42,000 children were living in RTCs. Given the expansion of children living in RTCs, see supra note 2, this figure is likely well over 50,000 now.

[4] Reports to staff attorneys at the Bazelon Center for Mental Health Law. For example, in Washington, D.C., children are certified to go to RTCs by a “Multi-Agency Planning Team” process (or MAPT process). The MAPT meetings often do not include the voices of the people who know the child and family best.

[7] This development of long-term residential care occurred at the expense of community-based alternatives. Jane Knitzer, as far back as 1982, noted that: “In general, funds were used to develop long-term residential care, with few efforts to support or create emergency shelters, respite care programs, or specialized foster care for disturbed children and adolescents.” Unclaimed Children, supra note 2, at 46. Further, the Surgeon General noted that one of the primary reasons that RTCs are considered to be justified is because community-based alternatives are lacking. SeeMental Health: A Report of the Surgeon General, supra note 1.

[8] Duchnowski, A.J., Hall, K. S., Kutash, K, and Friedman, R. (1998) The Alternatives to Residential Treatment Study, in Outcomes for Child and Youth with Behavioral and Emotional Disorders and Their Families. See alsoMental Health: A Report of the Surgeon General, supra note 1.

[12]Mental Health: A Report of the Surgeon General, supra note 1, (“Settings range from structured ones, resembling psychiatric hospitals, to those that are more like group homes or halfway houses.”); Rivera, V.R. & Kutash, K. (1994), Components of a System of Care. What Does the Research Say?, Tampa , FL: University of South Florida, Florida Mental Health Institute: The Research and Training Center for Children’s Mental Health.

[13] Jane Knitzer noted this fact in 1982 in Unclaimed Children, supra note 2, at 46. The calls for reform have only increased as the population of children served in RTCs has grown. See infra at note 29 and accompanying text.

[25] National Council on Crime and Delinquency, Focus Newsletter, July 16, 2002 (“[Residential treatment centers] are usually some distance from the youth’s community, alienating the youth from his or her known environment and adding communication and travel costs to the families and communities.”)

[28] Since their inception, RTCs have been under-monitored. As Jane Knitzer noted in Unclaimed Children,supra note 2 at 46: “States have not emphasized continued monitoring of children’s care once they are in residential treatment.” Many RTCs are not accredited at all. Further, the RTCs that are certified are accredited by the Joint Organization on Accreditation of Healthcare Organizations (JCAHO), an independent, nonprofit organization. But as many have pointed out “JCAHO’s standards are geared mainly toward monitoring surgical and pharmacological procedures. And so RTCs, which are more like boarding schools than traditional hospitals, can become accredited under standards that have little to do with the daily programs and activities practiced in them.” Meza-Wilson, A. & Harrison, C., Safe Choices for Troubled Teens: Residential treatment centers for troubled teens are plagued by allegations of abuse and ineffectiveness. But do anguished parents have an alternative?, August 12, 2004, available at: http://www.askquestions.org/articles/teens/.

[30]Id. Further, the Bazelon Center has been contacted by federally funded Protection and Advocacy organizations who never or rarely received MUIs from the RTCs serving children within their jurisdiction.

[49]Id. The Surgeon General suggests that RTCs are often utilized because of the under-availability of community-based alternatives.

[50] Bruns, E.J., Serving Youths with Emotional and Behavioral Problems in Maryland: Opportunities for the Use of the Wraparound Approach, University of Maryland School of Medicine, Department of Psychiatry, September 17, 2003 (on file at the Bazelon Center).

The number of children placed in residential treatment centers (or RTCs)[1] is growing exponentially.[2] These modern-day orphanages now house more than 50,000 children nationwide.

Given the care given to children in orphanages around the world, and given the reputation that preceedes many orphanages (AKA a "pedophile's paradise"), I wonder WHY so many parents think RTC's are such a great, safe alternative for their adopted orphan children?

he was refused day treatment due to crappy school system (and why the school system gets to be the gate keeper for day treatment is beyond me) he is there over school issue and it is costing our state $12,000 per month.... day treatment would have cost about $32,000 for the entire year, but that was far less than the public alternative school...

the system is nuts....

he always did well in special needs parks and rec, but the school system treats him like crap and causes most of the problems he has.... He is frequently called faggot retard at school, spit on, pushed down, etc... he has autism, he cannot deal with it... his class is so much of a joke, they did a month long unit on putting dog food in baggies ... he does not really have mental retardation, but autism and IQ in the slow learner range....

actually a good many of the RTC in our state are being shut down, and theraputic foster care is on the big rise and actually often costs as much as RTCs did... but they will do far and above more for a child in theraputic foster care than they will for a kid living in his birth home or adoptive home...

I worry if autistic children are being put in RTC's that "specialize" with children given the RAD label. [In fact, the RAD label itself bothers me because often times there are so many other disorders that are associated with the RAD child; it's hard to tell if RAD is a singular diagnosis or one that combines ADHD, PTSD, FAS, depression, autism, and so on.] In any case, I don't think all "special needs" cases are the same, so I don't know how RTC's address the individual needs of each type of "disordered child". As a parent, I would worry very much about the safety of my child living with other kids with "disturbed behavior", especially if the RTC (and my child) were far away from me.

It just so happens this morning I was reading an article about Theraputic Foster Care:

In the past, Children Services has been forced to place children in need of therapeutic placements in homes outside the county through private agencies.

"The cost for a child in traditional care is $25 per day for children 12 and under. For children 12 and up, it is $30 per day. The cost for a child in therapeutic foster care is about $125 per day while children in residential treatment facilities require $225 per day," Reeves said.

Crawford County spends about $1.2 million per year on foster care.

"By finally having the ability to license therapeutic foster homes in our own county, we will save the taxpayers money and be able to use that money for other services to help the families in our own county," O'Leary said. [From: "Crawford County working to add therapeutic foster care", Kimberly Gasuras, March 7, 2009, http://www.bucyrustelegraphforum.com/article/20090307/NEWS01/903070303 ]

I'm sure most kids, in general, don't care how much something costs parents or taxpayers. I DO think most kids do not want to be moved far away from family, friends, and an area that has become "home" to them. (Good or bad, don't most people think familiarity breeds it's own personal sense of comfort?)

When I was little, I always though the parent who sent a child far away from home was doing that because the parent no longer wanted to see or be with the child. For some, that could be seen as a reward. For others, that can easily feel like a punishment.

Either way, logic in my mind dictates a simple rule: when a person feels forced to stay in a home with people he/she hates, it's easy to see how/why bad behavior escalates.

All mental disorders bother me. For some reason the diagnostic approach of the medical profession is being used to categorize phenomena in the mental realm, even though the there is not really a proper ground for that. It sometimes is already hard to reduce the human body to its functional components, but to degree we can pinpoint certain medical conditions as related to certain organs. With mental disorders such is not possible. The brain simply cannot be reduced to a set of components with certain functions, yet that is what diagnostics relies upon. As a result most phychiatrtist and psychologists will give a diagnosis they are most familiar with. Someone specialized in ADHD will more often give the diagnosis ADHD than someone specialized in PTSD. In other cases people will be diagnosed with a personality disorder that is a mix of Borderline. Narcisistic and Histrionic, which in fact means, the psychiatrist in question has no clue.

In all honesty, I don't believe all these conditions really exist, which is not to say people cannot have mental issues, but that there is no simple singular cause to the problems experienced. The field of diagnostics, I believe, exists because only given a diagnosis can a treatment be prescribed, while in reality treatment is mostly experimental. Sometimes it works, sometimes it doesn't work, in which cases something else is tried.

They call it structured living and activities, but when there are locks on the bedrooms and front doors, it's jail. Locking 15 teen boys in a structure; boys with many different needs and abilities is asking for trouble. And when the needs center around sexually abused teen boys, there is a big probability the teens will use each other sexually. This is what happened at my son's RTC. They even went to the public school where it happened. Loading them into vans to go to a movie and it happened. Yep, jail with perks...